Spine Surgery and Preoperative Hemoglobin, Hematocrit, and Hemoglobin A1c: A Systematic Review

The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for the Mitigation of Complications of Neurostimulation

INTRODUCTION

The International Neuromodulation Society convened a multispecialty group of physicians based on expertise and international representation to establish evidence-based guidance on the mitigation of neuromodulation complications. This Neurostimulation Appropriateness Consensus Committee (NACC)® project intends to update evidence-based guidance and offer expert opinion that will improve efficacy and safety.

MATERIALS AND METHODS

Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to October 2023. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant.

RESULTS

The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process.

CONCLUSIONS

The NACC recommends best practices regarding the mitigation of complications associated with neurostimulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.

The Influence of Preoperative Anticoagulant and Antiplatelet Therapy on Rebleeding Rates in Patients Suffering from Spinal Metastatic Cancer: A Retrospective Cohort Study

INTRODUCTION

The age of patients requiring surgery for spinal metastasis, primarily those over 65, has risen due to improved cancer treatments. Surgical intervention targets acute neurological deficits and instability. Anticoagulants are increasingly used, especially in the elderly, but pose challenges in managing bleeding complications. The study examines the correlation between preoperative anticoagulant/antiplatelet use and bleeding risks in spinal metastasis surgery, which is crucial for optimizing patient outcomes.

MATERIAL AND METHODS

In a retrospective study at our department from 2010 to 2023, spinal tumor surgery patients were analyzed. Data included demographics, neurological status, surgical procedure, preoperative anticoagulant/antiplatelet use, intra-/postoperative coagulation management, and the incidence of rebleeding. Coagulation management involved blood loss assessment, coagulation factor administration, and fluid balance monitoring post-surgery. Lab parameters were documented at admission, preop, postop, and discharge.

RESULTS

A cohort of 290 patients underwent surgical treatment for spinal metastases, predominantly males (63.8%, n = 185) with a median age of 65 years. Preoperatively, 24.1% (n = 70) were on oral anticoagulants or antiplatelet therapy. Within 30 days, a rebleeding rate of 4.5% (n = 9) occurred, unrelated to preoperative anticoagulation status (p > 0.05). A correlation was found between preoperative neurologic deficits (p = 0.004) and rebleeding risk and the number of levels treated surgically, with fewer levels associated with a higher incidence of postoperative bleeding (p < 0.01).

CONCLUSIONS

Surgical intervention for spinal metastatic cancer appears to be safe regardless of the patient's preoperative anticoagulation status. However, it remains imperative to customize preoperative planning and preparation for each patient, emphasizing meticulous risk-benefit analysis and optimizing perioperative care.

Do Osteobiologics Augment Fusion in Anterior Cervical Discectomy and Fusion Surgery Performed With Mechanical Interbody Devices (Polyether ether ketone, Carbon Fiber, Metal Cages) and is the Fusion Rate Comparable to that With Autograft? A Systematic Review

STUDY DESIGN

Systematic Review of the Literature.

OBJECTIVE

The purpose of this study was to perform a systematic review describing fusion rates for anterior cervical discectomy and fusion (ACDF) using autograft vs various interbody devices augmented with different osteobiologic materials.

METHODS

A systematic review limited to the English language was performed in Medline, Embase and Cochrane library using Medical Subject Heading (MeSH) terms. Studies that evaluated fusion after ACDF using autografts and osteobiologics combined with PEEK, carbon fibre, or metal cages were searched for. Articles in full text that met the criteria were included in the review. The main outcomes evaluated were the time taken to merge, the definition of the fusion assessment, and the modality of the fusion assessment. The risk of bias of each article was assessed by the MINORS score or ROB 2.0 depending on the randomisation process.

RESULTS

The total number of references reviewed was six hundred and eighty-two. After applying the inclusion criteria, 54 were selected for the retrieval of the full text. Eight studies were selected and included for final analysis in this study. Fusion rates were reported between 83.3% and 100% for autograft groups compared to 46.5% and 100% for various interbody device/osteobiological combinations. The overall quality of the evidence in all radiographic fusion studies was considered insufficient due to a serious risk of bias.

CONCLUSION

Mechanical interbody devices augmented with osteobiologics performed similarly to autografts in terms of reliability and efficacy. Their time to fusion and fusion rate were comparable to autografts at the end of the final follow-up.

Preoperative Optimization: Risk Factors for Perioperative Complications and Preoperative Modification

Adult spinal deformity (ASD) is common and the complication rate in ASD surgery is high due to its invasiveness. There are several factors that increase the risk of complications with ASD surgery. These include age, past medical history, frailty, osteoporosis, or operative invasiveness. Risk factors for perioperative complications can be categorized as modifiable and non-modifiable. The purpose of this article is to present the current available evidence on risk factors for perioperative complications, with a focus on frailty, osteoporosis, surgical site infection prevention, and hip-spine syndrome. In addition, we present the latest evidence for patient-specific surgical risk assessment and surgical planning.

Preoperative glycated hemoglobin concentration and early postoperative infections in patients undergoing spinal surgery: A systematic review

Early postoperative infections can affect a significant number of spinal surgery patients. Many studies reported on the features that may associate with elevated risk of infectious complications in this group. Data on the impact of glucose metabolism disorders in this area are well known. At the same time information on the correlation of preoperative HbA1c level and postoperative infections in spinal surgery are still scarce. Furthermore there are no strict recommendations regarding routine HbA1c testing prior to elective surgery. In present SR we aimed to report available clinical evidence on association between preoperative HbA1c and early postoperative infections. We used PubMed and EMBASE database and a set of specific key words (spine surgery AND infections AND HbA1c) to identify eligible studies. The study was registered in PROSPERO database and reported according to PRISMA recommendations. 16 studies were selected for further assessment. Predominance of data indicated a significant correlation between preoperative HbA1c concentration and elevated risk of postoperative infections, as well as higher rate of non - infective complications and worse patients future outcome. Adequately designed future studies on purposely dimensioned sample size are needed to confirm the role of preoperative HbA1c testing in preoperative management of spinal surgery patients.

Enhanced Recovery After Surgery Protocols and Spinal Deformity

The authors outline a review of preoperative, intraoperative, and postoperative considerations surrounding adult spinal deformity. Preoperative management topics include imaging, hemoglobin A1c levels before spine surgery, osteoporotic management, and prehabilitation. Topics surrounding intraoperative management include the use of antibiotics, liposomal bupivacaine, and Foley catheters. The authors also discuss postoperative questions surrounding analgesia, nausea and vomiting, thromboembolic prophylaxis, and early mobilization. Throughout their discussion, the authors incorporate enhanced recovery after surgery protocols to hopefully lead to future discussions regarding optimizing complex spinal patients.

Clinical outcomes and prediction nomogram model for postoperative hemoglobin < 80 g/L in patients following primary lumbar interbody fusion surgery

OBJECTIVE

To analyze the association between different postoperative hemoglobin (Hb) levels and postoperative outcomes in patients who have undergone primary lumbar interbody fusion, and to investigate the risk factors and establish a predictive nomogram mode for postoperative Hb < 80 g/L.

METHODS

We retrospectively analyzed 726 cases who underwent primary lumbar interbody fusion surgery between January 2018 and December 2021in our hospital. All patients were divided into three groups according to the postoperative Hb levels (< 70 g/L, 70-79 g/L, ≥ 80 g/L). The postoperative outcomes among the three groups were compared, and the risk factors for postoperative Hb < 80 g/L were identified by univariate and multivariable logistic regression analysis. Based on these independent predictors, a nomogram model was developed. Predictive discriminative and accuracy ability of the predicting model was assessed using the concordance index (C-index) and calibration plot. Clinical application was validated using decision curve analysis. Internal validation was performed using the bootstrapping validation.

RESULTS

Patients with postoperative Hb < 80 g/L had higher rates of postoperative blood transfusion, a greater length of stay, higher rates of wound complications, and higher hospitalization costs than those with postoperative Hb ≥ 80 g/L. Preoperative Hb, preoperative platelets, fusion segments, body mass index, operation time, and intraoperative blood loss independently were associated with postoperative Hb < 80 g/L. Intraoperative blood salvage was found to be a negative predictor for postoperative Hb < 80 g/L (OR, 0.21 [95% CI 0.09-0.50]). The area under the curve of the nomogram model was 0.950. After internal validations, the C-index of the model was 0.939. The DCA and calibration curve suggested that the nomogram model had a good consistency and clinical utility.

CONCLUSIONS

Postoperative Hb < 80 g/L in patients following primary lumbar interbody fusion surgery increased blood transfusions requirement and was independently associated with poor outcomes. A novel nomogram model was established and could conveniently predict the risk of postoperative Hb < 80 g/L in patients after this type of surgery.

The impact of aquatic exercise programs on the systemic hematological and inflammatory markers of community dwelling elderly: A randomized controlled trial

Evidence shows that physical exercise is important in maintaining an efficient immune system during ageing. However, there are few studies that test the impact of aquatic exercise programs on the immune system. This study aims to analyze the impact of different physical exercise programs in aquatic environment on the systemic hematological and inflammatory markers of community dwelling elderly. One hundred and two elderly were randomly allocated into four groups: a continuous aerobic exercise group (AerG) (n = 25, 71.44 ± 4.84 years); an interval aerobic exercise group (IntG) (n = 28, 72.64 ± 5.22 years); a combined exercise group (ComG) (n = 29, 71.90 ± 5.67 years); a control group (CG) (n = 20, 73.60 ± 5.25 years). The AerG, IntG and ComG participants took part in three different aquatic exercise programs over a 28-weeks period. The CG participants maintained their usual routines during the same time period. Blood samples were collected from all participants in order to access hematologic indicators, by means of cell count, and the inflammatory profile by ELISA. After 28 weeks, significant differences were found for several hematologic variables in the AerG, IntG and ComG with increases in mean corpuscular hemoglobulin (MCH), mean corpuscular hemoglobulin concentration (MCHC), and hemoglobulin (Hb). Decreases in TNF-α levels were found for all exercising groups. An increase in IL-10 levels, granulocytes to lymphocytes ratio (GLR) and a decrease in the TNF-α/IL-10 ratio, were found for the IntG. For the ComG decreases were also found for the TNF-α, IL-1ß/IL-1ra ratios. The present study suggests that aquatic exercise programs were able to improve the inflammatory profile of the participants. Those in the exercise intervention groups showed a shift towards lower pro-inflammatory levels while the non-exercising group showed the opposite behaviour. The IntG and the ComG aquatic exercise programs appeared to be more effective than the AerG program in decreasing chronic low-grade inflammation by mediating the production of higher levels of anti-inflammatory cytokines. However, the differences found between the exercising groups were small and may not have clinical significance.

Development and validation of a risk-based algorithm for preoperative type and screen testing in spine surgery

BACKGROUND CONTEXT

With improvements in surgical techniques and perioperative management, transfusion rates after spine surgery have decreased over time. Given this trend, routine preoperative ABO/Rh type and antibody screen (T&S) laboratory testing may not be warranted in all patients undergoing spine surgery.

PURPOSE

The aim of the current study is to evaluate risk factors for intra/postoperative transfusion in patients undergoing a variety of spine procedures and to develop an algorithm for selectively ordering preoperative T&S testing in appropriate patients.

STUDY DESIGN/SETTING

This is a single institution, retrospective observational study of patients undergoing emergent or elective spine surgery. External validation of the algorithm was performed on a national sample of patients undergoing spine surgery from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) national database.

PATIENT SAMPLE

A total of 5,947 surgeries from January 1, 2016 to December 31, 2019 at a single institution, and 166,113 surgeries from the 2016 to 2018 ACS-NSQIP database.

OUTCOME MEASURES

The primary outcome measure was performance of intraoperative or postoperative transfusion.

METHODS

Using the institutional sample, univariate statistics (chi-square tests, fisher's exact test, 2-sided independent sample tests) were performed to compare demographics, comorbidities, and surgical details (case type, number of levels treated, etc.) between patients who did and did not require intra- or postoperative transfusion. Transfusion rates were calculated and compared across procedure types. Multivariate logistic regression was performed to identify independent predictors of transfusion and the model's accuracy was evaluated using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. A risk-based algorithm suggesting no preoperative T&S in low transfusion risk procedures, routine preoperative T&S in high-risk procedures, and further assessment in medium risk thoracolumbar fusion procedures was created. The algorithm's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were evaluated when it was applied to both the institutional and national samples. Potential cost savings from reducing T&S orders were calculated.

RESULTS

In the institutional sample, 120 patients (2.0%) required intraoperative or postoperative transfusion. The highest rates of transfusion were found in corpectomy (10.5%) and anterior/posterior cervical fusion (6.9%) procedures. In the multivariate logistic regression model, the presence of a preoperative coagulation defect or hemorrhagic condition (OR: 7.149, p<.001) and 6+ level surgery (OR: 7.511, p<.001) were the strongest predictors of transfusion. Overall, the model generated an AUC of 0.882, indicating excellent predictive accuracy. When applied to the institutional cohort, the risk-based algorithm had a sensitivity of 78.3%, specificity of 80.5%, PPV of 7.6%, and NPV of 99.4% for evaluating likelihood of transfusion. Using the algorithm 4,717 T&S tests would have been eliminated (79.3%), resulting in a cost savings of $179,246. Application of the model to the ACS-NSQIP cohort resulted in a sensitivity of 61.9%, specificity of 84.6%, PPV of 15.6%, and NPV of 98.0%.

CONCLUSIONS

The routine use of preoperative ABO/Rh type and antibody screen testing does not appear to be warranted in patients undergoing spine surgery. A risk-based approach to preoperative type and screen testing may eliminate unnecessary tests and generate significant cost savings with minimal disruption to clinical care.

Peri-operative Takotsubo syndrome after non-cardiac surgery: a retrospective nested case-control study

AIMS

Takotsubo syndrome (TTS) is an acute reversible cardiac dysfunction that may occur during the peri-operative period and among patients with serious illness. We aimed to evaluate the clinical characteristics, peri-operative management, and prognosis of peri-operative TTS (pTTS) and explore the factors associated with pTTS.

METHODS

We conducted a retrospective nested case-control study using the database of patients who underwent in-hospital non-cardiac surgeries between January 2017 and December 2020 in Peking University Third hospital. Cases were adult patients diagnosed TTS at discharge who were matched with four controls based on operative types. Multivariable conditional logistic regression was used to identified the factors associated with pTTS. The area under the curve (AUC) was used to evaluate the diagnostic efficacy.

RESULTS

Among the 128 536 patients underwent non-cardiac surgery, 20 patients with pTTS and 80 patients without were enrolled in this study. The incidence of pTTS was about 0.016% in our centre. The median age of patients with pTTS was 52.5 (38.25, 76.25) years, although 90% of them were female. Fifty per cent (9 cases) of female patients were pre-menopausal. Caesarean section has the highest proportion of pTTS (30% of the pTTS cases) with the incidence of caesarean section-related pTTS of 0.06% in our centre. A high prevalence of non-apical ballooning pattern of regional wall motion abnormality (seven cases, 35%) and a high mortality (two cases, 10%) were observed. Left ventricular ejection fraction (LVEF) of patients with pTTS was significantly decreased (41.7 ± 8.8%). In the acute phase, supportive treatments aiming to reduce life-threatening complications were main treatment strategies. After receiving systematic treatment, significant improvements were observed in LVEF (63.1 ± 13.5%), with median recovery time of LVEF of 7.48 days. Leucocyte count [odds ratio (OR): 4.59; 95% confidence interval (CI): 1.10-19.15], haemoglobin (HGB) (OR: 10.52; 95% CI: 1.04-106.36), and the revised cardiac risk index (RCRI) score (OR: 6.30; 95% CI: 1.05-37.88) were the factors significantly associated with pTTS. The RCRI score performed poorly in the prediction of pTTS (AUC: 0.630; 95% CI: 0.525-0.735). After adding leucocyte count and HGB into the RCRI score, the AUC was significantly improved (AUC: 0.768; 95% CI: 0.671-0.865; P = 0.001).

CONCLUSIONS

Patients with pTTS have some differences compared with common TTS, including higher proportion of pre-menopausal female, higher prevalence during caesarean section, higher prevalence of non-apical ballooning pattern of regional wall motion abnormality, and higher mortality. The RCRI score performed poorly in the evaluation of pTTS. Adding HGB and leucocyte count into the RCRI score could significantly improve its predictive performance.

Development and Validation of Predictive Model—HASBLAD Score—For Major Adverse Cardiovascular Events During Perioperative Period of Non-cardiac Surgery: A Single Center Experience in China

Background

Major adverse cardiovascular events (MACEs) represent a significant reason of morbidity and mortality in non-cardiac surgery during perioperative period. The prevention of perioperative MACEs has always been one of the hotspots in the research field. Current existing models have not been validated in Chinese population, and have become increasingly unable to adapt to current clinical needs.

Objectives

To establish and validate several simple bedside tools for predicting MACEs during perioperative period of non-cardiac surgery in Chinese hospitalized patients.

Design

We used a nested case-control study to establish our prediction models. A nomogram along with a risk score were developed using logistic regression analysis. An internal cohort was used to evaluate the performance of discrimination and calibration of these predictive models including the revised cardiac risk index (RCRI) score recommended by current guidelines.

Setting

Peking University Third Hospital between January 2010 and December 2020.

Patients

Two hundred and fifty three patients with MACEs and 1,012 patients without were included in the training set from January 2010 to December 2019 while 38,897 patients were included in the validation set from January 2020 and December 2020, of whom 112 patients had MACEs.

Main Outcome Measures

The MACEs included the composite outcomes of cardiac death, non-fatal myocardial infarction, non-fatal congestive cardiac failure or hemodynamically significant ventricular arrhythmia, and Takotsubo cardiomyopathy.

Results

Seven predictors, including Hemoglobin, CARDIAC diseases, Aspartate aminotransferase (AST), high Blood pressure, Leukocyte count, general Anesthesia, and Diabetes mellitus (HASBLAD), were selected in the final model. The nomogram and HASBLAD score all achieved satisfactory prediction performance in the training set (C statistic, 0.781 vs. 0.768) and the validation set (C statistic, 0.865 vs. 0.843). Good calibration was observed for the probability of MACEs in the training set and the validation set. The two predictive models both had excellent discrimination that performed better than RCRI in the validation set (C statistic, 0.660, P < 0.05 vs. nomogram and HASBLAD score).

Conclusion

The nomogram and HASBLAD score could be useful bedside tools for predicting perioperative MACEs of non-cardiac surgery in Chinese hospitalized patients.

Prediction of Long-Term Recovery From Disability Using Hemoglobin-Based Models: Results From a Cohort of 1,392 Patients Undergoing Spine Surgery

Hemoglobin and its associated blood values are important laboratory biomarkers that mirror the strength of constitution of patients undergoing spine surgery. Along with the clinical determinants available during the preadmission visit, it is important to explore their potential for predicting clinical success from the patient's perspective in order to make the pre-admission visit more patient-centered. We analyzed data from 1,392 patients with spine deformity, disc disease, or spondylolisthesis enrolled between 2016 and 2019 in our institutional Spine Registry. Patient-reported outcome measure at 17 months after surgery was referred to the Oswestry disability index. High preoperative hemoglobin was found to be the strongest biochemical determinant of clinical success along with high red blood cells count, while low baseline disability, prolonged hospitalization, and long surgical times were associated with poor recovery. The neural network model of these predictors showed a fair diagnostic performance, having an area under the curve of 0.726 and a sensitivity of 86.79%. However, the specificity of the model was 15.15%, thus providing to be unreliable in forecasting poor patient-reported outcomes. In conclusion, preoperative hemoglobin may be one of the key biomarkers on which to build appropriate predictive models of long-term recovery after spine surgery, but it is necessary to include multidimensional variables in the models to increase the reliability at the patient's level.

Severity of Preoperative HbA1c and Predicting Postoperative Complications in Spine Surgery

BACKGROUND

Diabetes mellitus (DM) is associated with a greater incidence of perioperative complications. The measurement of hemoglobin A1c (HbA1c) has not been routinely used in the preoperative assessment for spine surgeries.

METHODS

In the present single-institution, prospective study, HbA1c testing was included in the preoperative laboratory examination of patients undergoing spinal surgery from 2016 through 2018. The HbA1c levels were categorized using the American Diabetes Association guidelines as normal (HbA1c <5.7%), pre-DM (HbA1c 5.7%-6.4%), and diabetes (HbA1c >6.5%). Those with a HbA1c of ≥8% were separated as having poorly controlled DM for analysis. Perioperative complication and comorbidity data were collected to assess for associations with DM using logistic regression models. Odds ratios (ORs) and 95% confidence intervals were computed.

RESULTS

A total of 440 patients (238 men, mean age, 56.43 ± 13.28 years; mean body mass index, 30.80 ± 6.65 kg/m²) met the study criteria. The HbA1c was <5.7% in 206 patients (46.8%), 5.7%-6.4% in 148 (33.6%), 6.5%-7.9% in 64 (14.5%), and ≥8.0% in 23 patients (5.22%). Bivariate logistic modeling showed that patients with poorly controlled DM had a higher risk of complications (OR, 2.92) than did the patients with DM (OR, 2.13). Malignancy (OR, 2.62) and hypertension (OR, 1.86) were also significant risk factors for complications. However, smoking (OR, 0.83) was not significant. Poorly controlled DM remained associated with complications in multivariable logistic regression modeling (OR, 2.72).

CONCLUSIONS

Poorly control DM defined by the preoperative HbA1c was significantly associated with postoperative complications. Smoking, however, was not so associated. Preoperative HbA1c can be used to assess the risk of postoperative spine surgery complications.